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Vol. 44 

Friday, 21 August 1964 

No. 4 




The Laboratory Diagnosis of Intestinal 
Malabsorption Syndrome 


Renal Failure and the Artificial 

Kidney 7 

The Orthopaedic Management 

of Rheumatoid Arthritis ....... 1 1 


RADM Eighmy Assumes New 

Dutie s at BUMED 15 

Proper Completion of the Report 

of Medical Examination 16 

Job Opportunities for Ex- 
Hospital Corpsmen 17 

Public Papers of the U. S. 

Presidents 18 

Changes in Army PG Courses ... .18 


BUMEDINST. 6120. 13C 19 

Seminar on the Prophylaxis of 

Streptococcal Infection 19 

Biomedical Exchanges Center .... 19 
Naval Medical Research Reports. . .20 

Biologic Variation In Human 

Pulpal Studies 22 

Aids in Preventive Dentistry 27 


Committee on Aviation Pathology 

Convenes at AFIP. 27 

Determination of Fire Hazard in 

a Five Psia Oxygen 28 

Atmosphere at One and Zero 

Gravities 28 

Flight Physiology Notes 30 

Air Div. Aviation Medicine Unit . . .34 


USNH, Yokosuka - Intern Training 
Program .^ 36 


Active Duty for Training 
New Film Ready for Showing. 


MEDiCAl Ll'Su^Y 

United States Navy 

Vol. 44 Friday, 21 August 1964 No. 4 

Rear Admiral Edward C. Kenney MC USN 
Surgeon General 
Rear Admiral R. B. Brown MC USN 
Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 
Contributing Editors 

Aviation Medicine Captain C. E. Wilbur 

Dental Section Captain C. A. Ostrom 

Occupational Medicine .CDR N. E. Rosenwinkel 

Preventive Medicine Captain J. W. Millar 

Radiation Medicine .CDR J. H. Schulte 

Reserve Section. .Captain K. W. Schenck 

Submarine Medicine. .CDR J. H. Schulte 
















The U.S. Navy Medical News Letter is basically an official Medical Depart- 
ment publication inviting the attention of officers of the Medical Department 
of the Regular Navy and Naval Reserve to timely up-to-date items of official 
and professional interest relative to medicine, dentistry, and allied sciences. 
The amount of information used is only that necessary to inform adequately 
officers of the Medical Department of the existence and source of such infor- 
mation. The items used are neither intended to be, nor are they, susceptible 
to use by any officer as a substitute for any item or article in its original 
form. All readers of the News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Ch ange of Address 

Please forward changes of address for the News Letter to: Commanding Offi- 
cer, U. S. Naval Medical School, National NaVal Medical Center, Bethesda, 
Maryland 20014, giving full name, rank, corps, and old and new addresses. 

The issuance of this publication approved by the Secretary of the Navy on 
4 May 1964. 

U. S. Navy Medical News Letter, Vol. 44, No. 4 3 


Laboratory Diagnosis 
Intestinal Malabsorption Syndrome 

LT Donald O. Castell MC USN* and LT Larry G. Dickson MC USN**. 
U.S. Naval Medical Laboratory Quarterly 2(2): 11-15, April 1964. 

In a previous issue of the Quarterly, a method for the examination of "capsule 
biopsies" of the alimentary canal was presented. Laboratory aids in the di- 
agnosis of various malabsorption syndromes of the small and large intestine 
are not limited to describing such small specimens. Several clinical patho- 
logic studies also aid in establishing such diagnoses. 

Passage of nutrients across the interface of the intestinal mucosa de- 
pends upon two basic physiologic processes: (1) Digestion and (2) absorption. 
If digestive hydrolysis is faulty, ingested complex compounds are presented 
to the above interface in a state unsuitable for satisfactory absorption. A com- 
monly cited abnormality of this nature occurs with deficiency of formation or 
flow of pancreatic juice. Absorption may "be abnormal if the intestinal mucosa 
at the proper level is diseased or functionally absent. Functional or anatomic 
absence may result from surgical removal, surgically created by-pass flow 
of intestinal contents, or spontaneously occurring blind pouches or fistulas of 
congenital or inflammatory origin. 

Clinical laboratory studies used in this field fall into the following ma- 
jor groups: 

1. Tolerance studies -producing a "flat curve" if absorption is dimin- 

2. Quantitative fecal determinations of dietary constituents. 

3. Radioactive isotopic tracer studies with determination of 

a. Fecal excretion c. Urinary excretion levels 

b. Absorbed level in blood and/or rates 

In each instance it must be emphasized that both the "raw product" food- stuff 
product and the pre-hydrolyzed product may be administered with benefit. 
Isolated abnormal absorption of the un-hydrolyzed food suggests the basic de- 
fect is one of the digestive phase; diminished absorption of the pre-digested 
food suggests absorption as the phase which is abnormal. 

Steatorrheais possibly the most common manifestation of malabsorption 
whichbrings a patient to the care of a physician. A simple reliable screening test 
for abnormal fecal fat excretion is available and has proven to be reliable in 
diagnosing steatorrhea and in following patient response to therapy: 

* Senior Resident in Internal Medicine, U. S. Naval Hospital, Bethesda, Md. 
** Fourth Year Resident in Pathology, U. S. Naval Medical School, NNMC, 
Bethesda, Md. 

4 U, S. Navy Medical News Letter, Vol. 44, No. 4 

Principle: Fecal fat is stained with ethanolic Sudan IV 

a. On two numbered (1 and 2) glass slides place 0. 5 cc of patient's stool. 

b. Slide 1 : 

1. Add 2 drops of water and thoroughly mix with specimen 

2. Add 2 drops of 95% ethanol and mix 

3. Add 2-3 drops of a saturated solution of Sudan IV in ethanol 

4. Mix and cover with cover slip 

5. Examine the slide under "high-dry" magnification paying special 
attention to the edges of the smear 

c. Slide 2: 

1. Add 2-3 drops of 35% acetic acid and mix thoroughly 

2. Add 2-3 drops of the Sudan IV solution used above, mix and cover 
with cover slip. 

3. Heat slowly until the mixture starts to boil then allow to cool briefly 

4. Repeat step (3) twice more 

5. Examine while still warm, using the method described above 

a. Slide number 1: If present, neutral fat will appear on this slide as yellow 
or pale-orange refractile globules. In normal patients few if any small 
globules will appear. 

b. Slide number 2: Stained fatty acids appear as globules when warm. As 
the preparation cools, similarly stained spicules and amorphous masses 
of fatty acid crystals form. 

Inte rpretation: 

An experienced examiner is requiredjhowever ;such facility is rapidly 

a. Normal: 0-100 tiny globules per field (1-4 u diameter) 

b. Abnormal: 

1. Minimal-moderate: 40-500 globules measuring 10-50 u in diameter 

2. Marked: many fields packed with globules measuring 10-75 u in 

Clinical Significance: 

a. Increased neutral fat:(Slide 1 positive) - generally decreased digestion 
due to pancreatic disease with decreased exocrine function 

b. Increased fatty acids:(Slide 2 positive) - digestion normal but steator- 
rhea due to faulty absorption 

The above determination is performed with the patient ingesting a normal 

Other clinical laboratory studies which are useful in diagnosing malabsorption 
with steatorrhea include the following: 

1. Standard quantitative determination of fecal fat. The method presented in 
the Biochemistry Manual, U.S. Naval Medical School, 1959, pp 171-174 
is desirable because it is a "percentage-dry weight" method. (Normal: 
5. 8-25. 6% dry weight). 

U.S. Navy Medical News Letter, Vol. 44, No. 4 5 


2. I labeled lipid (labeled triolein or oleic acid) with determination of re- 
sidual activity in the stool or blood activity at a given time following oral 

3. Serum carotene. This is proportional to the absorption of the fat soluble 
VitaminA. The alcohol/ether extraction spectrophotometry method is good 
(Clinical Laboratory Diagnosis, Levinson, S. A. andMacFate, JR. P. , Lea and 
Febiger, Philadelphia, 1961, pp 379-380). (Normal: 70-250 micrograms per 
deciliter plasma or serum). Blood carotene is lowest in primary malabsorp- 
tion and will return quickly to normal when treatment is successful. High 
fever, hepatic failure and dietary deprivation will also decrease the level. 
High levels are encountered in VitaminA intoxication (as following ingestion 
of polar bear liver), carotenemia, hypothyroidism, diabetes and with any 
cause of hyperlipemia. 

4. Serum cholesterol 

5. Serum calcium (reflecting Vitamin D absorption) 

6. Prothrombin time (reflecting Vitamin K absorption) 

Substances other than lipids are also abnormally absorbed in malabsorption 
syndromes. Protein may be incompletely absorbed as part of a malabsorption 
syndrome or, in the "exudative enteropathies" such as regional enteritis, pro- 
tein may be lost from the blood stream into the intestinal lumen. Such deter- 
minations include: 

1. Serum protein (electrophoresis preferred) 

2. Stool protein 

3. Intravenous administration of I -polyvinyl-pyrrolidone (PVP)orCr - 
albumin. The stool is monitored for radioactivity. Increased appearance 
of the label in the stool generally indicates an exudative process in the ab- 
sence of significant gastrointestinal hemorrhage. 

Similarly, carbohydrate digestion and absorption may be evaluated by the fol- 
lowing laboratory methods: 

1. D-xylose tolerance test: Xylose is a pentose which follows the absorption 
pathways of glucose. It is, however, metabolically inert and appears in the 
urine in amounts equal to those absorbed. The patient is given a "loading 
dose" and the urinary excretion is followed. The spectrophotometric method 
of Roe and Rice (J BiolChem 173: 507, 1948) is convenient and satisfactory. 
When a 250 Gm dose is given to an adult (or 0. 50 Gm/pound in children) 
0. 5 Gm/pound or more should be excreted after five hours. Less than 
2. 5 Gm indicates severe malabsorption. 

2. Glucose tolerance test: when absorption is decreased, the curve will be 
"low and flat. " 

3. Starch tolerance test: when the above are normal and carbohydrate malab- 
sorption is still suspected, ingestion of starch will cause a blood glucose 
rise similar to (2) above in the normal; if carbohydrate digestion is faulty, 

6 U. S, Navy Medical News Letter, Vol. 44, No. 4 

the blood glucose will rise only slightly and return to base-line levels more 
rapidly than normal. Patients do not generally like the taste of starch. 

Miscellaneous tests which may be indicated include: 

1. Stool examination for ova, parasites and blood 

2. Urinary 5-hydroxy-indol acetic acid (5-HIAA). Argentaffine cells are more 
numerous in sprue, celiac disease, regional enteritis, Whipple's disease, 
Menetrier's disease and other chronic inflammations of the Argentaffine 
cells and the coupled local hyperemia, the serum and urinary levels of 
5-HIAA are increased. 

3. Barium enema and small bowel series 

4. Hemogram with or without bone marrow examination 

5. FIGLU determination 

6. Schilling test 

Whenever a large battery of tests may be indicated for a given patient one may 
assume that the clinical picture of intestinal malabsorption may be caused by 
many disease entities. The following is a collection of conditions presenting 
as a problem in malabsorption: (by anatomic site) 

1. Stomach 

a. Pernicious anemia 

b. Post surgery 

(1) Gastrectomy (especially 
Billroth II procedure) 

(2) Pyloroplasty 

(3) Vagotomy 

2. Hepatobiliary 
a. Cholestasis 

(1) Intrahepatic 

(2) Extrahepatic 

3. Pancreatic disease: 

a. Fibro-cystic disease 

b. Chronic pancreatitis 

c. Carcinoma of the pancreas or ampulla of Vater 

d. Post-pancreatectomy state 

e. Starvation (decrease pancreatic digestive enzyme formation) 

f. Zollinger -Ellison syndrome (diarrhea more characteristic than steator- 

4. Small intestine: 

a. Sprue constellation: (? intestinal mucosal peptidase deficiency) 

(1) Tropical sprue 

(2) Non-tropical spure 

(3) Celiac disease 

b. Diverticulum or blind pouch 

c. Whipple's disease (intestinal lipodystrophy) 

d. Fistula 

U.S. Navy Medical News Letter, Vol. 44, No. 4 7 

e. Resection of small bowel {usually only if greater than 50% removed) 

f. Enteritis 

(1) Regional enteritis 

(2) Tuberculosis 

(3) Diffuse malignancy such as superficial spreading carcinoma of the 

(4) Diffuse lymphoma 
{5) Scleroderma 

(6) Amyloidosis 

(7) Congestive right heart failure (edema of the intestinal mucosa, 
sub-mucosa and pancreas decreases local metabolism) 

(8) Starvation with protein deprivation (intestinal mucosal atrophy) 

(9) Drug injury (local effect due to prolonged exposure to such agents 
as Neomycin) 

(10) Congenital absence of sugar transport enzymes 

(11) Acute bacterial and viral infections 

(12) Giardia lamblia infestation 

(13) Diphyllobothrium latum infestation 

(14) Hookworm infestation 

(15) Acanthrocytosis (a-beta-lipoproteinemia); this causes the inability 
to form chylomicra for the transport of absorbed lipid from the 
intestinal mucosa 

(16) Menetrier's disease (Giant hypertrophy of the gastric mucosa) 

(17) Small bowel diverticulosis 

(18) Radiation enteritis 

(19) Diabetes - this may be associated with increased intestinal motility 
due to autonomic dysfunction 

(20) Superior mesenteric artery insufficiency 

SJ5 3/gi rf. iff! *^C 5-gL 

Renal Failure and the Artificial Kidney 

B.G. Clarke M D,* Associate Professor of Urology, Tufts University School 
of Medicine and J. Hartwell Harrison MDt*Clinical Professor of Genito- 
urinary Surgery, Harvard Medical School. Reprinted by permission of the 
authors from "Diseases of the Urinary and Genital Organs" (A Review and 
Bibliography) - pps 130-135, Boston, Mass. , I960. *** 

During the past fifteen years great advances have been made in the manage- 
ment of renal failure both acute and chronic. Better understanding of the path- 
ologic physiology and accompanying biochemical and metabolic disturbances 
of the uremic states has led to improved treatment of electrolyte and water 
imbalance by conservative medical means. Additional effective therapy has 
been gained by various forms of dialysis both intracorporeal and extracor- 
poreal. External dialysis was first performed experimentally by Rowntree, 

U.S. Navy Medical News Letter, Vol. 44, No. 4 

Abel, and Turner in 1913 using collodion as a membrane and hirudin as an 
anti- coagulant. In 1944 Kolff successfully carried out external hemodialysis 
in the human for the first time. This was now possible because of availability 
of cellophane as a dialyzing membrane and of heparin as an anti-coagulant. 
Walter in 1948 designed an improved modification of Kolff dialyzer and this 
was put to excellent experimental and clinical use by Merrill and associates 
at the Peter Bent Brigham Hospital in the study and treatment of severe renal 
failure. The following table from Merrill compares cellophane with the glo- 
merular capillary. 

Cellophane Total Human Glomerular 


Fractional Pore Area 
Total Area 
Pore Radius 
Pore Length 

30 - 35% 
22,000 Gm 2 
30 Angstrom 
tfO M 

7600-15000 Grr/ 
30-45 Angstrom 

1 M 

Changes effected during a six hour dialysis employing the Kolff rotating type 
of artificial kidney with a blood flow of 200 cc per minute are shown below 
from Merrill. 









27 mm/h 



140 mEq/h 



4 mEq/h 




Blood Hr. 6 Hr. Initial Co mposition of Bath 

Uric acid (mg%) 
Creatinine (mg%) 
C02 mm/h 
Na mEq/h 
K mEq/h 

Multiple efforts at improvement of the artificial kidney have been made by 
Kolff, Alwall, Murray, Skeggs and Leonards, Murphy and Rosenack. The use 
of this complex apparatus has been largely developed by effective teams work- 
ing in the larger medical centers throughout the world and their contributions to 
the general care of renal failure have extended far beyond the use of the arti- 
ficial kidney alone. Other methods of dialysis that have been studied are peri- 
toneal lavage, replacement transfusions, intestinal lavage and isolation of a 
jejunal loop for intermittent lavage. 

In the absence of an obstructive lesion causing anuria, the electrolyte 
imbalance of acute renal failure is treated by restriction of fluids ;hyper tonic 
dextrose, insulin and sorbitol for K intoxication. Chronic acidosis requires 
careful administration of sodium and calcium e specially when congestive failure 
has demanded digitalization. When anuria persists and conservative measures 
fail to control electrolyte imbalance, especially potassium intoxication, then 

U. S. Navy Medical News Letter, Vol. 44, No. 4 9 

external dialysis is used to accomplish the selective removal of electrolytes 
and metabolites in a period of several hours. Restoration of normal acid -base 
balance and correction of K intoxication occur rapidly. Improvement of the 
chronic uremic patient from a state of torpor to alert consciousness has been 
impressive. The artificial kidney has been useful in the treatment of severe 
acute glomerulonephritis as a life saving measure until natural renal recovery 
has occurred;it has been especially valuable in the treatment of acute tubular 
nephropathy following major surgery, mismatched transfusion and hemolytic 
postpartum crises. The profound hypotension at times complicating biliary 
surgery and hepatic failure has been successfully combated by external dialysis. 
The preparation of patients having chronic renal failure for necessary surgery 
such as removal of neoplasms or transplantation of the kidney itself has been 
accomplished by external dialysis pre-operatively and further security obtained 
in the post-operative period by further hemodialysis when necessary. The 
availability of an experienced team and the artificial kidney has permitted the 
performance of desirable elective surgery on patients having chronic renal in- 
sufficiency that would not have been safe or justifiable without this security in 
the post-operative period. 

An extensive program in the study of the homologous transplantation 
of the human kidney has developed from the studies by the team at the Brigham 
Hospital devoting their efforts to renal failure. 

The Treatment of Renal Failure. Merrill, J. P. : Grune & Stratton. New York, 

London. 1955. 
The Place of the Artificial Kidney in Research and Treatment. Harrison, J. H. : 

J Urol 70: 559-567, October 1953. 
Peritoneal Dialysis. 1. Technique and Applications. Maxwell, M. H. ; Rockney, 

R. E. ; Kleeman, C. R. ; and Twiss.M. R. : JAMA 170: 917-924, June 20, 

Acute Renal Failure. Franklin, S. S. ; and Merrill, J. P. : New England J Med 

262: 711-718, 761-767, April 7 & 14, I960. 

Renal Transplantation 

Historical . Nephritis with irreversible renal failure, or accidental loss of all 
functioning kidney tissue are the indications for kidney replacement by trans- 
plantation. Autog rafted kidneys, transplanted from one to another location in 
the same animals, survive indefinitely and function normally, as far as may 
be determinedbyany available test. Successful permanenthomotransplantation 
of kidneys in animals and man had not been accomplished until 1954. Previous 
attempts at homografting had been technically successful and the kidneys had 
resumed functionjbut anuria had always developed within a few days or weeks. 
The principal pathologic change, presumably due to an immune reaction, was 
lymphocytic infiltration of the transplanted kidney and eventual failure of func- 

10 U, S. Navy Medical News Letter, Vol. 44, No. 4 

Corneal homotransplants had been successfully practiced for some 
time. Homografting of skin between identical twins had been accomplished by 
Brown in 1937. Between antigenically dissimilar twins, however, rejection of 
kidney and skin transplants had been the rule. In 1954, homotransplantationof 
the kidney was successfully accomplished at the Peter Bent Brigham Hospital 
between identical twins who had undergone successful preliminary skin ex- 
change grafts. The recipient, a young man who was in the terminal stage of 
glomerulonephritis, had been prepared for surgery with the use of the artifi- 
cial kidney. 

Clinical Considerations . Twelve (12) pairs of identical twins have, at 
the time of writing, undergone renal homotransplantation for advanced renal 
failure due to nephritis. The vessels of the donor kidney were anastomosed to 
the hypogastric vessels of the recipient, and the ureter to the bladder. Eleven 
of the 12 patients had return of their renal function to normal by all available 
tests and the longest survival until the present has been 4 1 /2 years. One trans- 
plant was a technical failure. Although in each case the two original, diseased 
kidneys were surgically removed after recovery from the grafting operation, 
one patient died 4 months after transplantation because the transplanted kidney 
became involved with the patient's original glomerulonephritis. One of the pa- 
tients successfully completed a pregnancy. 

The General Problem of Renal Transplantation . The wider applicabil- 
ity of renal transplantation as a therapeutic technic in kidney disease a- 
waits clearer understanding of the antigen -antibody mechanism. Experimen- 
tally, attempts are being made to modify the antigenic reaction of donated 
tissue, and to eliminate antibodies in the host. Total body irridiation has been 
utilized in the attempt to eliminate the antibody reaction of the recipient. De- 
sensitization technics are undergoing study. The solution to the problem of 
tissue transplantation, however, seems to lie in the destruction of some es- 
sential element of individual specificity which, however, has not yet been ac- 

Successful Homotransplantation of the Human Kidney Between Identical Twins. 

Merrill, J. P. ; Murray, J. E. ; Harrison, J. H. ; and Guild, W. F. : JAMA 160: 

277-282, January 28, 1956. 
Kidney Transplantation Between Seven Pairs of Identical Twins. Murray, J. F. : 

Merrill, J. P. ; and Harrison, J. H. : Ann Surg 148: 343-359, 1959. 
Plastic Surgery: Tissue and Organ Homotransplantation. Cannon, B. ; and 

Murray, J. E. : New England J Med 255: 900-904, November 8, 1956. 

Selected Reading List 

Unilateral Nephrectomy in Hypertensive Disease. Smith, H. W. : J Urol 76: 

685-701, December 1956. 
Results of Nephrectomy in Hypertensive Patients. Thompson, G. J. : J Urol 77: 

358-363, March 1957 

U.S. Navy Medical News Letter, Vol. 44, No. 4 11 

The Cure of Hypertension by Nephrectomy. A Ten Year Follow-Up of a Case. 

Burkland, C. E. ;Goodwin, W. E. ; and Leadbetter, W. F. : Surgery 29: 67-70, 

July 1950. 
Thromboendarterectomy for Hypertension Due to Renal Artery Occlusion: 

Freeman, N. E. ; Leeds, F. H. ; Elliott, W. G. ; and Roland, S. I. : JAMA 156: 

1077-1079, November 13, 1954. 
Renal Hypertension. Dustan,H. P. ;Page, I. H. ; and Poutasse, E. F. : New 

England J Med 261: 647-653, September 24, 1959. 
The Kidneys in Surgery of the Abdominal Aorta. Szilagyi, D. E. ; Smith, R. F. ; 

and Whitcomb, J. G. : AMA Arch Surg 79: 252-265, August 1959. 
Bilateral Stenosis of Renal Arteries and Hypertension. Treatment by Arterial 

Homografts. Poutasse, E. F. ; Humphries, A. W. ; McCormack, L. J. ; and 

Corcoran, A. C. : JAMA 161 : 419-423, June 2, 1956. 
Severe Hypertension Due to Congenital Stenosis of Artery to Solitary Kidney: 

Correction by Splenorenal Arterial Anastomosis. DeCamp, P. T. ; Snyder, C. 

H. ;and Bost, R. B. : AMA Arch Surg 75: 1023-1026, December 1957. 

The above list is concluded from the Medical News Letter 44(3): 13, 1964. 

* Doctor Clarke's current address is 1224 Jefferson Bldg. , Peoria, Illinois 
61602. He holds the rank of Commander in the Medical Corps of the Ready 
Reserve and is engaged in the private practice of Urology. He served as 
a medical officer on active duty with the Navy during World War II and the 
Korean Conflict. We are indebted to both authors for this opportunity to re- 
publish their material. 
** Doctor Harrison holds the rank of Lt. Col. MC AUS, Retired. 
*** Doctors Clarke and Harrison had a thousand copies of this publication made 
and distributed to students and house officers at Harvard and Tufts. The 
supply is now exhausted. Through special permission of the authors, it is 
planned to republish in future issues of the Medical News Letter, selected 
papers from this excellent 137-page document. —Editor 

3JC ifZ f,-, <|i *[* ijC 

The Orthopaedic Management 
of Rheumatoid Arthritis 

LCDR Richard B. Gresham MC USN* and LCDR Benjamin J. Gilson MC 
USN**. Proceedings of the Monthly Staff Conferences of the U. S. Naval 
Hospital, NNMC, Bethesda, Md. , 1963-1964. 

Since the advent of the polio vaccine the orthopaedist has had more time to 
consider difficult diseases such as congenital musculo-skeletal defects and the 
deformities of the collagen diseases. 

Once the diagnosis of rheumatoid arthritis has been established, the 
patient should immediately be referred to the orthopaedic surgeon so that 

12 U.S. Navy Medical News Letter, Vol. 44, No. 4 

instruction may be given inthe prevention of joint deformities. This is especial- 
ly true for the patient who is seen in the acute stages. It is during this period 
that the deformities rapidly develop and, if not controlled, progress to a fixed 
condition not amenable to cons ervative management. The pathology producing 
the deformities requiring orthopaedic treatment is basically the same in all 
joints. The inflammatory process, characterized by chronic inflammatory 
cells, is most prominent in the synovial membrane and as a pannus invading 
articular cartilage and subchondral bone. 

It is this primary inflammatory pathosis that is responsible for the 
skeleto-muscular deformities which are seen in rheumatoid arthritis. The 
synovitis produces the boggy joints, laxity of the capsule, pain and flexion 
contracture. The contracture is initially a reversible phenomenon due to the 
massive proliferation of the synovial membrane which acts as a space occupying 
lesion, thus limiting motion. There is a secondary muscular splinting of the 
joint because of pain, the joint assuming the position of least discomfort. A 
third factor in the production of joint contractures is the inflammatory involve- 
ment of the muscles resulting in a spastic type of contracture which will ulti- 
mately become permanent as the muscles degenerate in their pathological 


Once joints become immobile, the inflammatory pannus can destroy 
the articular cartilage from two directions, directly over the surface and by 
means of the subchondral invasion. The destruction of the cartilaginous portion 
of the joint can re suit in an osseo-ankylosis of the articulating bones. In some 
cases there is a bony hypertrophy rather than bone destruction. This is most 
marked about the knee and hip. 

Co nservative Management . The conservative management may be di- 
vided into three major areas: 

1. Chemical control of discomfort with drugs. 

2. Mechanical control of joint contractures with functional splinting. 

3. Active control of joint function with physical therapy. 

During the acute phase of the disease the severe contractures from the inflam- 
matory process are reversible. During this stage, the involved joints must be 
splinted in functional positions. The splints will have to be removed at least 
once daily to apply physical therapy techniques to maintainboth active and pas- 
sive motion. It is only during these severe acute attacks that systemic steroids 
may have to be used for short periods of time to maintain joint function. As the 
patient's condition improves and contractions are overcome, splints have to 
be changed to meet the new condition. If the disease primarily involves just 
one joint it may be controlled to some degree with the use of local steroids 
injected intra-articularly. This procedure may be repeated several times, but 
overuse can result in neurotrophic -like changes in the joint. The early surgical 
removal of the synovial membrane in involved tendons and some joints such as 
the knee and metacarpophalangeal joints of the fingers may be considered a 
conservative measure compared to the drastic procedures which must be per- 
formed in the late stages of the disease. 

U.S. Navy Medical News Letter, Vol. 44, No, 4 13 

The large number of drugs available to relieve the discomfort of arthritic 
diseases permits flexibility in meeting individual needs. The development 
of the steroids as a therapeutic agent seemed to be a solution to the discomforts 
of arthritis; however, time has shown that the systemic use of these drugs does 
not significantly alter the course of the disease process. Their use requires 
progressively larger doses and often leads to side effects which make the 
chronic reconstruction phase of the disease much more difficult. Most notable 
among the adverse effects of systemic steroids may be a "chemical adrenal- 
ectomy, " which increases surgical risk and osteoporosis. This increases 
susceptibility to fractures and makes surgery involving osteosynthetic re- 
construction more difficult. The longer patients remain on the systemic steroids 
the more vexing it becomes to withdraw the drug. In some instances the mental 
depression associated with withdrawal renders such measures impossible. To 
prevent these problems, systemic steroids should either not be used at all, or 
used only as a last resort for short periods not exceeding two or three weeks. 

Hand . Direct involvement of the intrinsic musculature of the hand adds 
to the joint pathology to create progressive deformity and relative imbalance 
of action with the extrinsic tendons. There is gradual ulnar drift of the fingers 
with shortening of the lateral bands. Angulation and subluxation of the metacarpo- 
phalangeal joints permit further displacement of extensor tendons, which 
frequently come to lie within the gutters between the metacarpal heads. This 
may progress to complete dislocation of the joint. Relative over -pull of the 
intrinsic s may result in the "intrinsic plus" deformity, with flexion of the 
distal interphalangeal joint and hyperextension of the proximal interphalangeal 

Recent emphasis on surgical treatment of rheumatoid arthritis has 
stressed the benefits attainable in the hand. Chemical and surgical synovecto- 
mies and repositioning of subluxed tendons will significantly increase function, 
as will surgical release of contracted lateral bands. Late changes may require 
arthroplasties of these joints. Selected fusions of the interphalangeal joint or 
metacarpo-phalangeal joint of the thumb may serve to recover tactile opposi- 
tion. The weak first dorsal interosseous muscle may gain supplemental power 
by extensor indicis proprius transfer. Prosthetic replacement of joints may 
have merit particularly in the metarcarpo -phalangeal area. 

Hip . The primary process of synovitis and joint destruction is accel- 
erated in the heavy weight-bearing joints of the body such as the hip and knee. 
The painful hip assumes a position of flexion and external rotation. Once this 
process has resulted in joint destruction and fixed contractures, major re- 
constructive surgery is all that is available to the patient. In most cases this 
is some type of arthroplasty. The more common type is that of a metallic cup 
arthroplasty in which the joint is cleaned of its synovial membrane and artic- 
ular cartilage on both the acetabular and femoral sides. The cup is fitted to 
the femoral headand acts as an interposing movable partition in the joint. The 
results are less than perfect and relief of discomfort is relative, but some 
degree of weight-bearing motion is preserved. 

14 U. S. Navy Medical News Letter, Vol. 44, No. 4 

Stem types of prosthetics have been used to replace the femoral head 
in rheumatoid arthritis, but with less success than the cups. The poor quality 
of bone in these patients works against tolerance of the stem prosthesis, in 
that it tends to migrate in the acetabulum or work loose in the femoral shaft. 

Knee. The synovitis which involves the knee results in weakened quad- 
riceps, flexion contractures and joint destruction. Occasionally the hyper- 
trophic type of the disease will produce great thickening of the patella. The 
disuse associated with this process results in atrophy of the quadriceps mus- 
cle. This is probably enhanced by primary muscle involvement with the in- 
flammatory infiltrate. Once the chronic synovitis has developed, surgical ex- 
cision of this source of inflammatory pannus may delay the destructive course 
of the disease. If flexion contractures have developed, surgical capsulectomy 
may be necessary to restore extension. When advanced joint destruction has 
occurred, arthroplasty may be performed, using some type of synthetic or 
biological interposing membrane, such as nylon or fascia. The synovectomy 
is performed at the time of this procedure. These arthroplasties do not restore 
normal joint motion; they offer only relative relief of pain. 

Ankle. When the same destructive process involves the ankle, there 
is no surgery worthwhile. The ultimate result being dependent upon the ef- 
fectiveness of conservative measures to maintain a functional weight-bearing 

Foot. The arthritic involvement of the foot results in two major areas 
of deformities: the subtalar joint, and the digits. The affliction of the subtalar 
joint may produce a severe varus or valgus of the hind foot, which will require 
surgical correction and arthrodesis of the joint in a functional position. 

Involvement of the metatarsophalangeal joints and the toes is similar 
to the process as seen in the hand. However, because the fine movement of 
the toes is not necessary for walking, the deformities, although severe, are 
not functionally as significant. Of great importance, is the painful metatarsal 
callouses and bunions which develop. The contractures of the MP joints and 
PIP joint forces the metatarsal heads down and the PIP joint dor sally resulting 
in the plantar callouses and painful dorsal corns. Reconstruction of the tendons 
in an attempt to balance these joints is of no benefit. The procedure of choice 
is resection of the metatarsal heads and most, or all, of the proximal phalanx 
of the toes. This relieves the pressure points and eliminates the painful joints. 
Function after this mutilating procedure is surprisingly good. 

The orthopaedic management of rheumatoid arthritis consists of con- 
trol of pain with salicylates and heat, control of joint deformities with splints, 
exercise programs, and excision of focal synovial membranes, Control of 
rheumatoid arthritis from its onset, through its ultimate destructive chronic 
stages should be of primary concern to the orthopaedist. 

* Acting Chief of Orthopedic Service, USNH, Bethesda, Md. 
** Senior Resident in Orthopaedic Surgery, USNH, Bethesda, Md. 

$ $ :$; $ ;J: >|t 

U. S. Navy Medical News Letter, Vol. 44, No. 4 



RADM Eighmy 
Assumes New Duties in BuMed 

Rear Admiral Herbert H. Eighmy 
MC USN, reported to the Bureau 
of Medicine and Surgery, Navy 
Department, Washington, D. C. , 
this week for duty as Assistant 
Chief for Personnel and Profes- 
sional Operations. He reported 
to the Bureau from duty as Senior 
Medical Officer, U. S. Naval Acad- 
emy, Annapolis, Md. 

Admiral Eighmy attended Al- 
legheny College and graduated 
with the degeee of Doctor of Med- 
icine from Hahnemann Medical 
College in Philadelphia in 1933. 
He interned at Hahnemann Hospi- 
tal in Philadelphia and in 1935- 
36 was Resident Anaesthetist and 
later Chief Resident Physician 
there. He was commissioned in 
the Medical Corps, U. S. Navy in 
July 1936 as a Lieutenant (jg) and 
progressed in rank to that of 
Rear Admiral, to date from 
1 July 1964. 

Among his many duty stations were the Naval Hospitals, Philadelphia, 
San Diego, Newport, R.I, , St. Albans, Great Lakes, Camp Pendleton, and 
Pensacolaf^and duty aboard the following ships: USS RUSSEL,USS RAPIDAN, 
He has also had duty with the Naval Medical School, Bethesda, Md. , and the 
Naval Training Center, Norfolk, Va. He attended the Naval School of Aviation 
Medicine, Pensacola, Fla. , where he was designated a Flight Surgeonin July 
1941 and was serving as a Flight Surgeon at the Naval Air Station, Quonset 
Point, R. I, , at the outbreak of World War II. From November 1944 to April 
1946 he was Flight Surgeon of the USS BUNKER HILL which, with her Air 
Groups, won the Presidential Unit Citation with Star for heroic service in the 
{* Commanding Officer, U. S. Naval Hospital April 1960-July 1963) 

Rear Admiral H. H. Eighmy 
Official U. S. Navy photograph. U. S. 
Naval Academy, Annapolis, Md. 

16 U.S. Navy Medical News Letter, Vol. 44, No. 4 

Pacific from November 1943 until April 1945. He was personally awarded the 
Bronze Star Medal, with Combat "V" and the following citation: 

•For meritorious achievement as Senior Medical Officer of the USS 
BUNKER HILL during operations against enemy Japanese forces in the vicinity 
of Okinawa on May 11, 1945. After his ship had been damaged by heavy enemy 
air attacks, CDR Eighmy set up emergency battle dressing stations to replace 
those destroyed, gave medical attention to numerous seriously wounded men 
and led rescue parties into areas of fire and explosions to insure that wounded 
men were being treated and evacuated. His professional skill, courage and 
devotion to duty were in keeping with the highest traditions of the United States 
Naval Service. " 

In addition to the Bronze Star Medal and the Presidential Unit Citation 
Ribbon with Star, Admiral Eighmy has the American Defense Service Medal 
with Star; the American Campaign Medal; Asiatic -Pacific Campaign Medal; 
World War II Victory Medal; National Defense Service Medal; Navy Occupation 
Service Medal, Asia Clasp; Korean Service Medal with one operation star; and 
the United Nations Service Medal. He also holds the Navy Expert Pistol Shot 

Married to the former Maud Marie Leonard of Meadville, Penna. , 
Doctor Eighmy has two children, Barbara Ellen and Herbert Henry Eighmy, 
Jr. His official residence is Philadelphia, Penna. 

* * * * # * 

Proper Completion of 
the R eport of Medical Examination 

The importance of properly completed reports of medical examination (Stand- 
ard Forms 88, 89) must be continually stressed to all medical department per- 
sonnel concerned. If the personnel responsible (Medical officers, MSC officers 
and enlisted hospital corpsmen) would insure that the forms are complete in 
accordance with existing regulations and/or supported by such additional med- 
ical information that may be necessary in order to arrive at a sound clinical 
decision regarding physical fitness, most mistakes would be detected and cor- 
rected prior to submission. Listed below are some of the common errors noted 
upon review in BUMED and are provided for information and guidance of all 

a. Medical History. Failure to comment adequately on items of medical, 
personal, or family history related by applicant on SF 89. 

b. The Psyche. Failure to evaluate pertinent history concerning maturity, 
emotional stability, and suitability for service. See MANMED art. 15-7. 

c. Miscellaneous Considerations . Failure to obtain statement from person- 
al physician concerning history of asthma. 

History of asthma beyond age 12 reported as "NCD". See MANMED 
art. 15-8 (3) (f). 

U.S. Navy Medical News Letter, Vol. 44, No. 4 17 

d. Endocrine Glands and Metabolism. Failure to obtain standard glucose 
tolerance test in the presence of diabetes mellitus in a parent, sibling, 
or more than one grandparent. See MANMED 15-9 (3) (g). 

e. Color perception. Failure to conduct color perception tests and report 
the results of Farnsworth Lantern Test or pseudoisochromatic test 
plates properly. See MANMED art. 15-11. 

f. Heart and Blood Vessels. Failure to obtain the values of pulse and blood 
pressure (sitting position) in the AM and PM for 3 to 5 days without 
prolonged rest or any sedation when abnormal values are obtained on 
current examination. See End: (1) to BUMEDINST. 6120. 19. 

g. Genitourinary System. Failure to evaluate finding or history of albumin- 
uria. See MANMED 15-22 (1) (a). 

h. The Extremities. Failure to evaluate major joint for strength, mobility, 
stability, and functional capacity when, history of injury is present. See 
MANMED arts. 15-23 and 15-89A. 

i. The Teeth. Failure to indicate whether orthodontic appliances are 
"fixed" or "removable" and failure to include statement about the pre- 
sence and degree of facial deformity with the jaw in normal position in 
presence of malocclusion. See MANMED art. 15-25(6) (c) (6) and (7). 

j. The Nervous System. Failure to investigate history of syncope or loss 
of consciousness. See MANMED art. 15-24 (2) (f). 

k. Visual acuity. Failure to conduct and record visual acuity examinations 
properly, i. e. , failure to report corrected vision;failure to obtain state- 
ment of unaided visual acuity with and without refraction when vision 
does not fully correct; and failure to detect contact lenses. See MANMED 
arts. 15-10, 15-86 and 15-87. 

1. Standard Form 89. Failure to complete all Items (19, 20, 21, signatures). 

NOTE: In recent years a number of mechanically reproduced copies of Stand- 
ard Forms 88 have been forwarded to the Bureau, apparently as "originals. " 
Also certain activities have adopted the practice of preprinting clinical entries 
on these reports prior to actually conducting the examination. Such variations 
are not authorized by current regulations and for various legal and adminis- 
trative reasons are not acceptable. See MANMED art. 16-37(2). 

— Physical Qualifications and Medical Records Div. , BuMed. 

>\i Jijc s{c ijc qC 3gC 

Job Opportu nities for Ex-Hospital Corpsmen . Civil Service positions at cer- 
tain U. S. Naval Shipyard Dispensaries are available for personnel qualified as 
"Medical Radiology" and "Medical Technician. " Applicants may apply to the 
appropriate Regional Office of the Civil Service Commission for detailedinfor- 
mation. —Hospital Corps Division, BuMed. 

3<c sjc s$r sjt age iff 


U. S. Navy Medical News Letter, Vol. 44, No. 4 

latest Edition in the series of . . . 

John F. Kennedy, 1963 

Contains verbatim transcripts of the President's news conferences 
and speeches and full texts of messages to Congress and other mate- 
rials released by the White House during the period January 1- 
November 22, 1963. 

Among the 478 items in the book are: special messages to_ the 
Congress on education, youth conservation, needs of the Nation's 
senior citizens, and on improving the Nation's health ; radio and tele- 
vision addresses to the American people on civil rights and on the 
nuclear test ban treaty and the tax reduction bill ; joint statements 
with leaders of foreign governments ; and the President's final remarks 
at the breakfast of the Fort Worth Chamber of Commerce. Also 
included is the text of two addresses which the President had planned 
to deliver on the day of his assassination; President Johnson's proc- 
lamation designating November 25 a national day of mourning; and 
remarks at the White House ceremony in which President Kennedy 
was posthumously awarded the Presidential Medal of Freedom. 
Z3^vrt-x>r Ty*~ts*n* tn f\f\ A valuable reference source for scholars, reporters of current affairs 

100 I £ CI PeS LllCCt JiUtUU and the events of history, historians, librarians, and Government 

' O * officials. 

currently available: 











$6.75 1957 $6.75 

$7.25 1958 $8.25 

$6.75 1959 $7.00 

$7.25 1960-61 $7.75 


_ $9.00 




Volumes are published annually, soon after the close of each year. 
Earlier volumes are being issued periodically, beginning with 1945. 


• Messages to the Congress 

• Public speeches 

• The President's news conferences 

• Radio and television reports to the 
American people 

• Remarks to informal groups 

• Public letters 

Order from the: Superintendent of Documents 
Government Printing Office 
Washington, D.C. 20402 

From: FEDERAL REGISTER, the National Archives of the United States 29(132): 
9366, 8 July 1964. 

9JC $ 9JC JJS & $ 

Changes in Army PG Courses 

"Medical Aspects of Recovery from Thermonuclear Attack: Medical Manage- 
ment of Mass Casualties" has been cancelled. 

"Current Trends in Army Social Work" has been changed to 7-11 De- 
cember 1964. Both of these changes supersede the announcement in Medical 
News Letter 43{11), 5 June 1964. —Training Branch, Professional Div. , BuMed. 

sjf s£e sjz ?[< 3j-c 5,=: 

U. S. Navy Medical News Letter, Vol. 44, No. 4 19 



Subj: Procurement of civilian physicians to conduct physical 
examinations for reservists not on active duty 

Purpose. To provide certain guidelines for the examination of inactive 
reservists by civilian physicians and to delete the requirement that 
SFs 88 and 89 be submitted for Departmental review prior to final 
action in regard to enlistment of applicants in the Reserve program. 

BUMED INSTRUCTION 6120. 13B is cancelled and superseded. 

— Physical Qualifications and Medical Records Div. , BuMed. 

?'' -'; s!c 5?c & sic 

Eighth Annual Seminar on the 
Prophylaxis of Streptococcal Infection 

The subject Seminar, sponsored by the Armed Forces Epidemiological Board, 
will be held at the Medical Service School, Gunter Air Force Base, Alabama, 
29-30 October 1964. 

Only a limited number of officers can be authorized to attend the sem- 
inar on travel and per diem orders chargeable against Bureau of Medicine and 
Surgery funds. Eligible and interested officers who cannot be provided with 
travel orders to attend at Navy Expense may be issued Authorization Orders 
by their Commanding Officers following confirmation by this Bureau that space 
is available. Requests should be forwarded via chain of command, in accord- 
ance with BUMED INST. 1520. 8A. NOTE: The deadline date for receipt of 
requests in this Bureau is 2 September 1964. 

— Training Branch, Professional Div. , BUMED. 

Biomedical Materials Exchange Center . Some of the tissues most currently 
in demand from the Center include: 

1. Fresh frozen functioning ovarian tumors for in vitro incubations. 

2. Functioning pheochromocytomas, fresh frozen for metabolic studies. 

3. Freshly excised human thyroid tissue, normal and pathologic. 

4. Serum from patients with Hashimoto's disease, or other forms of 
chronic thyroiditis with hypothyroidism. 

5. Fabry's disease. 7. Frozen Tumor tissue. 

6. Papillary ependymoma. 8. Amyloid tissue. 

Please do not send the materials, but inform AFIP where they may be obtained. 
Letters should be addressed to the Director, Armed Forces Institute of Patho- 
logy, Washington, D. C. , 20305, Attn: Biomedical Materials Exchange Center. 

20 U. S. Navy Medical News Letter, Vol. 44, No. 4 

Naval Medical Research Reports 

U.S. Naval Medical Research Institute, NNMC, Bethesda, Md. 
1. Treatment of Experimental Frostbite with Low Molecular Weight Dextran: 
MR 005.02-0020.01 Report No. 1, March 1964. 

U.S. Naval Hospital, Navy Prosthetic Research Laboratory, Oakland 14, Calif . 

1. An Oral Gelatin-Xylose Test for Estimating Pancreatic Proteolytic Acti- 
vity: MR 005. 12-1408.4 Subtask 4, April 1964. 

2. Hydroxyproline Excretion in Endocrine Disease: MR 005. 12-1408.4 
Subtask 4, April 1964. 

U. S. Naval School of Aviation Medicine, Naval Aviation Med ical Center, 
Pensacola, Fla. 

1. The Validity of the Oculogravic Illusion As A Specific Indicator of Otolith 
Function: MR 005. 13-6001 Subtask 1 Report No. 67, February 1962. 

2. The Relationship of Small Visual Acuity Defects to the Ability to Complete 
Flight Training and Perform in Operational Flying. A Ten-Year Progress 
Report: MR 005. 13-3001 Subtask 3 Report No. 2, April 1963. 

3. The December 1962 Report of the RBE Committee to the ICRP and ICRU 
in its Implications for the Assessment of Proton Radiation Exposure in 
Space: MR 005. 13-1002 Subtask 1 Report No. 26, October 1963. 

4. Exclusion of Angular Accelerations as the Principal Cause of Visual 
Illusions During Parabolic Flight Maneuvers: MR 005. 13-6001 Subtask 1 
Report No. 85, October 1963. 

5. Instrumentation for the Pensacola Centrifuge -Slow Rotation Room 1 Fa- 
's cility: MR 005. 13-6001 Subtask 1 Report No. 88, October 1963. 

6. A Signal Conditioner and Electrode Technique for Nystagmus Measure- 
ments: MR 005. 13-6001 Subtask 1 Report No. 78, 1963. 

7. Vestibular Habituation During Repetitive Complex Stimulation -A Study of 
Trahsfer^Effects: MR 005.13-6001 Subtask 1 Report No. 93, January 1964. 

8. Significant Physiological Parameters of the Ballistocardiogram as Analyzed 
by a Mathematical Model: MR 005. 13-7004 Subtask 6 Report No. 11, 
January 1964. 

9. Influence of Strong Magnetic Fields on the Electrocardiogram of Squirrel 
Monkeys ( Saimiri Sciureus ): MR 005. 12-9010 Subtask 1 Report No. 8, 
March 1964. 

10. Use of Caloric Test in Evaluating the Effects of Gravity on Cupula Dis- 
placement: MR 005. 13-6001 Subtask 1 Report No. 94, April 1964. 

11. Prognostic Value of the Cold Pressor Test and the Basal Blood Pressure, 
May 1964. 

U.S. Navy Medical Neuropsychiatric Research Unit, San Diego, Cal if. 
1. Adaptation of Small Groups to Extreme Environments: MR 005. 12-2004 
Subtask 1, April 1963. 

U.S. Navy Medical News Letter, Vol. 44, No. 4 21 

San Diego, Calif, (cont'd ) 

2. Effective Individual Performance in Small Antarctic Stations: A Summary 
of Criterion Studies: MR 005. 12-2004 Subtask 1 Report No. 63-8, April 

3. Paroxysmal Eeg Activity and Cognitive -Motor Peformance: MR 005. 12- 
2304 Subtask 1 Report No. 63-1, April 1963. 

4. Biographical Indicators of Adaptation to Naval Service: MR 005. 12-2004 
Subtask 1 Report No. 63-19, November 1963. 

5. Personal History Correlates of Performance Among Military Personnel in 
Small Antarctic Stations: MR 005. 12-2004 Subtask 1 Report No. 63-20, 
November 1963. 

6. Past Experience, Self Evaluation, and Present Adjustment: MR 005. 12- 
2004 Subtask 1 Report No. 63-21, December 1963. 

7. Habituation of the Orienting Response in Alert and Drowsy Subjects: 
MR 005. 12-2304 Subtask 1 Report No. 63-17, December 1963. 

8. Computers in Brain Research: MR 005. 12-2304 Report No. 64-2. 

9. Value and Personality Differences Between Offenders and Non-offenders; 
MR 005. 12-2201 Subtask 1 Report No. 63-6. 

10. The Problem of Enuresis in the Naval Service: MR 005. 12-2201 Subtask 1 
Report No. 64-3, January 1964. 

11. Alpha Blocking and Autonomic Responses in Neurological Patients: MR 
005. 12-2304 Report No. 63-11, March 1964. 

12. Personal History Correlates of Performance Among Civilian Personnel in 
Small Antarctic Stations: MR 005. 12-2004 Subtask 1 Report No. 64-4, 
April 1964. 

13. Educational and Psychological Measurement: MR 005. 12-2201 Report No. 
63-2, Spring 1964. 

U. S. Naval Medical Research Unit No. 2, Taipei, Taiwan. 

1. Notes on the Mollusks ofLan Yu, Taiwan: MR 005. 09-1601 Subtask 3 
Report No. 21, June 1963. 

2. Study of Wilson's Disease in Taiwan: Report No. 63-5, September 1963. 

3. Gastrointestinal Physiology. Experimental Design Failure of an Oral Solu- 
tion Comparable to Stool in Volume and Electrolyte Composition to Re- 
place Stool Losses in Cholera Absorption of Oral Water in Cholera: 

MR 005. 09-1040. 1. 14, September 1963. 

4. Haptoglobin Type Distribution Among Filipino Residents of the Manila 
Area: MR 005.09-1601 Subtask 7 Report No. 5, September 1963. 

5. Laboratory Infection with Louping-Ill Virus: A Case Study: MR 005. 09- 
1201.2.12, November 1963. 

6. Classification of Trachoma Virus Strains by Protection of Mice from 
Toxic Death: MR 005.09-1201. 12.22, January 1964. 

7. Intestinal Parasites in an Aborigine Village in Southeast Taiwan: January 


22 U. S. Navy Medical News Letter, Vol. 44, No. 4 


An Approach to Biologic Variation in 
Human Pulpal Studies * 

Harold R. Stanley BS DDS MS** and Herbert Swerdlow BA DDS*** 
Bethesda, Maryland. J Pros Den 14(2): 365-371, March-April 1963. 

Through the years dental researchers have come to appreciate that the problem 
of biologic variation has made interpretation of human pulpal responses to 
various experimental procedures very difficult. Several recent investigations 
have shown, however, that this difficulty can be greatly minimized by merely 
having sufficient numbers and balanced quantities of teeth in both the experi- 
mental and control categories. Within a given category one must determine 
not only the range of responses to an experimental procedure but the average 
reaction as well. Nevertheless, as in most histopathologic investigations final 
results are never precisely clear cut to be graded "black" or "white". 

The feasibility of performing clinical research in dentistry is finally 
being realized. We, for example, have been fortunate at the National Institutes 
of Health in obtaining adequate numbers of teeth for pulp studies from patients 
at the Clinical Center, a clinical research institution. 

Persons were sought who possessed several intact vitalteeth (free from 
caries and restorations) which were to be extracted for prosthetic, periodontal, 
or orthodontic reasons, ''. Such subjects would then be admitted to a series 
of clinical projects, in addition to the pulpstudies, involving general anesthesia, 
wound healing, temporomandibular joint syndromes, and complete denture 
investigations. The subjects participating in these studies received the necessary 
* This abstract was prepared bythe authors of the original article. The infor- 
mation and the manner of presentation as written for the Journal of Prosthetic 
Dentistry were so outstanding that RADM F. M. KYES DC, USN, sought per- 
mission to reproduce the entire article in the U. S. Navy Medical News Letter . 
Since copyright laws prevented this, Doctors Harold R. Stanley and Herbert 
Swerdlow volunteered the preparation of this abstract. Their contribution is 
printed with grateful appreciation. 

** U.S. Department of Health, Education and Welfare, U.S. Public Health 
Service, National Institutes of Health, National Institute of Dental Research, 
Oral Medicine and Surgery Branch. 

*** U, S. Department of Health, Education and Welfare, U. S. Public Health 
Service, National Institutes of Health, Dental Department, Clinical Center. 

U. S. Navy Medical News Letter, Vol. 44, No. 4 23 

dental treatment in return for their cooperation in the projects. In this way, 
we have been able to obtain over 2,000 selected intact human teeth for pulpal 
studies in the past 8 years. 

Dentin Thickness . The most important single factor in determining 
pulpal response to a given stimulus is the remaining dentin thickness between 
the floor of the cavity preparation and the pulp chamber. This measurement 
differs from the depth of cavity preparation since the pulpal floor in deeper 
cavities on larger teeth may be farther from the pulp than smaller teeth with 
shallow cavities. Pulpal response becomes increasingly severe as the remain- 
ing dentin thickness decreases. 

At the risk of being facetious, it might be said that the problem of 
biologic variation would be simplified if human teeth were like elephant tusks. 
If a Class V cavity could be prepared with a sloping pulpal floor with increasing 
depth and consequently decreasing remaining dentin thickness, ranging from 
3. mm. to almost a pulpal exposure, we could greatly reduce the number of 
teeth needed for studying any one specific factor. By extracting such teethat 
each of three critical time intervals (1 day, 10 days and 120 days), the initial 
response, the fullest development of the lesion, and its resolution could be 

Because human teeth are too small to permit adequate and controlled 
sloping of the cavity floor, it is necessary to obtain adequate numbers of 
specimens at specific postoperative time intervals in order to balance the 
experiment. The data accumulated from approximately 25 specimens within 
a given postoperative time interval will provide the range of remaining dentin 
thicknesses needed. This information is then sorted and combined. 

The following schematic photographs are presented to illustrate the 
value of composite drawings for summarizing the data related to a specific 
experimental study. It should be emphasized that such drawings only give 
general insight in understanding the response to an experimental procedure. 
More exact and detailed information will be found in the respective references. 

Effects of Coolants . No response is induced by preparing a Class V 
cavity at 6,000 to 20, 000 r. p.m. when using a No. 37 diamond stone and an 
air-water spray and subsequently restoring it with zinc oxide and eugenol 
cement if 3.0 mm. of dentin remains (Fig.l). At 2. mm., a response is 
initiated and this increases in intensity as the pulp is approached. No burn 
lesions were created, even when the pulp was almost exposed. Although a 
Grade IV (XXXX) response may occur at low speed and air-water spray, the 
possibility of development of a nonreversible intrapulpal abscess is very slight 
when an air-water spray is used during preparation. The lesions created with 
the use of an air-water spray, regardless of speed, are always confined to 
the regions related to the ends of the cut dentinal tubules. ' 

Atthe low speeds it is irrelevant whether air -water spray or air alone 
is used in superficial cavities (Fig. 2). The potential for creating burn lesions 
becomes real only if the remaining dentin approaches a thickness of less than 
1. 5 mm. A resulting burn lesion can extend not only beyond the cut tubules 
but completely across the pulp chamber to the opposite surface of the tooth. 


U. S. Navy Medical News Letter, Vol. 44, No. 4 

COOLANT 6,000 ot 20,000 RPM #37 

6,000 ot 20,000 RPM #37 DIAMOND 




Fig. 1. 

Fig. 2. 

Fig. 1. The most critical factor in determining the degree of palpal 

response is the thickness of the remaining dentin (R. D. ) measured from the 
bottom of the cavity to the pulp. Given a constant cutting speed and technique, 
the intensity of the pulpal response increases as the R. D. decreases. No 
burn lesion will result at any cavity depth provided an adequate water coolant 
accompanies the procedure. 

Reproduced by permission of C. V. Mosby Co., St. Louis, Mo. 

Fig, 2. Without the use of an adequate water coolant, larger cutting tools, 

such as a No. 37 diamond stone, will create typical burn lesions within the 
pulp when the remaining dentin thickness becomes less than 1. 5 mm. 

Reproduced by permission of C. V. Mosby Co., St. Louis, Mo. 

About 23 per cent of all burn lesions become intrapulpal abscesses, the 
others being reversible with the formation of reparative dentin. The percent- 
age of reversibility would be less for cavity preparations in carious teeth which 
possess decreased pulpal resistance due to existing preoperative pathosis. 

For those who continue to cut with no coolant or with air alone, no burn 
lesion will develop with a No. 35 carbide bur at operating speeds of 6,000 or 

U. S. Navy Medical News Letter, Vol. 44, No. 4 


20,000 r. p. m. However, at the higher speeds, a No. 35 carbide bur will 
produce a burn lesion as readily as a dry diamond stone. 

Rotational Speeds. In Figure 3, low speed techniques are compared 
with high speed techniques. At the same remaining dentin thickness, higher 
speed techniques will induce half the pulpal response of the more traumatic 
lower speeds. At 1.0 mm. of remaining dentin, the average intensity of the 
inflammatory response is only Grade I (X) as compared to Grade III (XXX) with 
the low speed technique. *» 3 » 4 



Fig. 3. 

l£jLS-«iM//WM bBHTIH WitKHBSS (Hit/. 
I « DitUS OF hlPAL R£f?$MSl FXOH 
6A¥ITf PUPmttOH.l 

-}*ADPt8 m?Ai R£s?omnou 


4 I i 
Fig. 4. 

Fig. 3, Given adequate water coolants, the same cutting tools, and 

comparable remaining dentin thickness, the intensity of the pulpal response 
with the high speed techniques (decreasing force) is considerably less traumatic 
than the lower speed techniques (increasing force). 

———Reproduced by permission of C. V. Mosby Co. , St. Louis, Mo. 

Pig. 4. The insertion and condensation of amalgam in unlined cavities 

prepared with high speed instruments enhances the pulpal response intensity 
in such a way that the combination of high speeds in cavity preparation and 
amalgam restoration condensation equals the response of low speed cavity 
preparation alone. Much of the biologic advantage of the high speed technique 
is nullified. Reproduced by permission of C. V. Mosby Co., St. Louis, Mo. 

26 U. S. Navy Medical News Letter, Vol. 44, No. 4 

Amalgam Condensation . The biologic advantage of cutting- tooth struc- 
ture at high speed is sometimes reduced when followed by the insertion of 
certain filling materials. For example, inFigure 4, the pressures of amalgam 
condensation on virgin dentinal tubules unlined with reparative or secondary 
dentin intensified the pulpal response. The use of a cavity liner or base ma- 
terial capable of protecting and/or sealing the dentinal tubules not lined with 
reparative dentin is imperative prior to placing some restorative materials. 

Summary . Enough histopathologic studies have now been completed to 
provide reliable information concerning the response of the dental pulp to the 
newer cutting methods. Speeds above 50,000 r. p. m. have been found to be 
biologically acceptable to the pulp when controlling: 

( 1) the temperature with adequate coolants 

(2) force with smaller cutting tools 

(3) the remaining dentin thickness (R. D. ) with proper cavity depth 

(4) restorations with adequate protection to the pulp 

This article attempts to demonstrate the knowledge gained from experi- 
mental procedures affecting the human dental pulp through the use of composite 
drawings. The measures which can be taken to minimize the problem of 
biologic variations in pulpal studies are described. It is hoped that the general 
experimental approach discussed may stimulate other investigators to use 
for pulp studies those intact teeth that are to be extracted for various reasons. 


1. Swerdlow, H. , and Stanley, H. R. , Jr. : Reaction of Human Pulp to Cavity 
Preparation: Results Produced by Eight Different Operative Grinding 
Technics, JADA 58: 49-59, 1959. 

2. Swerdlow, H. , and Stanley, H. R. Jr. : Reaction of the Human Dental Pulp 
to Cavity Preparation. Part I. Effect of Water Spray at 20, 000 R. P. M. , 
JADA 56: 317-329, 1958. 

3. Swerdlow, H. , and Stanley, H. R. , Jr. : Human Pulpal Reactions Following 
20,000 and 150,000 R. P. M. Cavity Preparations, J D Res 37: 68, 1958. 
(Abst. ) 

4. Swerdlow, H. , and Stanley, H. R. Jr.: Reaction of the Human Dental Pulp 
to Cavity Preparation. Part II. At 150, 000 R. P. M. With Air -Water Spray, 
J Pros Den 9: 121-131, 1959. 

5. Swerdlow, H. , and Stanley, H. R. , Jr. : Response of Human Dental Pulp to 
Amalgam Restorations, Oral Surg., Oral Med. & Oral Path. 15:499-508, 

Progress in medical and dental research is developing at such a rapidrate 
that half of what physicians and dentists learn today will be obsolete in the 
next ten years. The information that is to replace the obsolete material is 
under investigation and is not yet known. 

Food and Nutrition News, January 1964. 

U. S. Navy Medical News Letter, Vol. 44, No. 4 27 

Preventive Dentistry Training Aids 

All dental activities are urged, in the development of their preventive dentistry 
educational programs, to use technical information and supplemental training 
aids provided by commercial firms and other dental institutions. To each 
dental department's professional judgment is delegated the authority to select 
material which will be most suitable. 

There are numerous firms which have prepared such material, some 
of which has been approved by the American Dental Association. Information 
concerning the availability of this material may be obtained by writing to 
BuMed (Code 611). 

^|S V|C -*|^ w g ^ ^ L i *j* 


Joint Committee on Aviation Pathology to Convene at AFIP 

WASHINGTON, D. C. , July 16, 1964 {AFIP) Officials of the Armed Forces 

Institute of Pathology have announced plans for the Fifth Scientific Session of 
the Joint Committee on Aviation Pathology to be held at the Institute Oct. 12-14. 

The Scientific Session, which will be held at AFIP on the grounds of the 
Walter Reed Army Medical Center in Washington, D. C. , will cover a wide 
range of subjects involving aerospace pathology and aircraft accident investi- 

Papers will be presented by military and civilian speakers from the 
United States, United Kingdom and Canada. Planned sessions include: legal 
aspects of aircraft accidents; pathological problems associated with mass 
casualties; preventive medicine and aviation; aircraft accidents at sea; investi- 
gation of aircraft accidents under difficult geographic conditions; recent work 
in anoxia and decompression; and aerospace toxicology. 

The Joint Committee on Aviation Pathology was established by the U. S. 
Department of Defense in 1955 as a central coordinating committee concerned 
with all matters relating to the role of pathology as applied to aviation and 
flight safety. Operating under the AFIP, the Committee serves as a focal point 
for the dissemination of information in those areas. 

Membership of the Committee consists of two representatives each 
from the three United States military services, the Royal Air Force, the Royal 
Navy, the Royal Canadian Air Force and the AFIP. Headquarters for the Com- 
mittee are located at the AFIP. Previous meetings have been held in all three 
of the participating nations. 

28 U. S. Navy Medical News Letter, Vol. 44, No. 4 

Application for registration for the Scientific Session should be made 
to: The Secretary, Joint Committee on Aviation Pathology, Armed Forces 
Institute of Pathology, Washington, D. C. 20305. Early application is recom- 
mended as the number which can be accepted is limited. 

—Submitted by - ILt. Melvin A. Mallory, Jr. , USAF, MSC 

Technical Liaison Officer 
576-2901 (Code 198) Ext. 2901 

Determination of Fire Hazard in a Five Psia Oxygen 
Atmosphere at One and Zero Gravities 

Arthur L. Hall* and Hwai S. Fang** 

Manytypes of artificial atmospheres have been studied in an effort to determine 
the optimum one for use in a space cabin or high altitude gondola. Mixtures 
of oxygen and nitrogen or some other inert gas, pure oxygen at some specific 
altitude pressure, or even terrestrial atmosphere at sea level pressure or less 
must be considered. After the breathing mixtures which will sustain life 
adequately have been selected, it is essential that each be evaluated in terms 
of the possibility of hazardous external fire. 

Previous experimentation in this respect has not been extensive. In 
studies of human subjects exposed to a simulated altitude of 34, 000 feet {3. 6 
pounds per square inch) with a 100 per cent oxygen atmosphere, an increase 
in rate of burning of paper at this partial pressure was noted. No ill effects 
of exposures for up to five days were observed in the subjects. 

Shternfeld stated that if, under conditions of weightlessness, a match 
is struck against the box, the head of the match will burst into flame, but the 
match will not ignite; no candle or gas will burn. He did not mention ambient 
gas mixtures. In his book, Soviet Space Science , the author wrote, "It should 
be noted that with a high amount of oxygen (in the cabin) the danger of fire 
increases, and food products rapidly oxidize and spoil; for this reason the 
microatmosphere must also contain a certain amount of other gases. " 

The Project Mercury capsule was designed to maintain an internal 
atmosphere pressure of 100 per cent oxygen at 5 pounds per square inch abso- 
lute (5 psia O2). This same atmosphere pressure was that of the Mercury full 
pressure suit, and plans for Apollo and Gemini include such a cabin atmosphere. 

For this reason it appeared worthwhile to investigate this particular 
atmosphere for external oxidation hazards, and future studies will examine 
some of the other gas mixtures which seem to sustain life adequately. To test 

* Ph. D. , U. S. Naval School of Aviation Medicine, Pensacola, Florida. 
** M. D. , Department of Physiology, School of Medicine, National Taiwan 
University, Taiwan, China. 

U. S. Navy Medical News Letter, Vol. 44, No. 4 29 

the validity of Shternfeld's statement that a candle will not burn under conditions 
of weightlessness, a series of 35 zero gravity parabolas of 25 to 28 seconds 
duration each were flown in a KC 135 airplane with a candle ignited in a test 
chamber. * 


Sea Level in Air. For control measurements, twenty standard ash-free 
paper strips were ignited, in sea level pressure in air, and ignition temperature 
as well as time in which one inch of the paper burned were recorded. Exposed 
to the heated elements for a maximum of fifteen seconds were: {1) four strips 
of the neoprene coated light weight nylon twill fabric, (2) six test strips of 
3.25 ounce nylon, (3) six test strips of vinyl plastic, and (4) four strips of 

aluminum plate. 

A 2 -inch piece of standard burn paper ignited by the heating element 
was placed on the shaved portion of the body of an Albino rat which had been 
sacrificed with pentobarbital. 

Toweling was dropped on top of an ignited paper burn strip as soon as 
the paper was aflame to determine the smothering properties of the toweling. 

Five Pounds Per Square Inch Oxygen Pressure . The low pressure 
chamber was evacuated to between 40,000 and 60, 000 feet of simulated altitude 
(2. 7 to 1. 04 psia) and flooded with oxygen until the simulated altitude was re- 
duced to 26,000 feet {5.2 psia) and the oxygen tension was stabilized in the 
inside atmosphere between 4. 8 and ,4. 9 psia. 

Twenty paper test strips were ignited after being in the 4. 8 to 4. 9 psia 
oxygen atmosphere for periods varying between five minutes and seven hours. 
Exposed to the 1800° F heating elements after being in the oxygen atmosphere 
for various time periods were: (1) five strips of the neoprene coated nylon 
twill fabric, (2) eight of the 3. 25 ounce nylon twill fabric, (3) eight vinyl plastic 
strips, and (4) four aluminum strips. 

The body of one shave rat which had been sacrificed remained in the 
oxygen atmosphere for five minutes at which time a test paper placed in con- 
tact with its body was ignited. Another rat remained alive for six hours in 
the same oxygen atmosphere before being sacrificed and exposed to the fire 
in a similar manner. 

After one hour in the oxygen atmosphere a test paper strip was ignited 
by the heating element. As soon as flame was observed, the towel smothering 
device was dropped into the fire. 


In air at sea level pressure, paper burned, and nylon, neoprene, and 

* Grateful acknowledgement is extended to the United States Air Force, 
Wright -Patters on Air Force Base, for the use oftheKC135 and for the help 
of numerous personnel. 

30 U. S. Navy Medical News Letter, Vol. 44, No, 4 

vinyl plastic melted. Skin of an exposed rat was singed. In the 5 psia oxygen 
atmosphere paper ignited at a lower temperature and burned approximately 
six times as fast. The other materials also burned, including exposed rats 
which were burned over their entire body. 

When the toweling was dropped on the paper test strip under sea level 
pressure in air, the fire was smothered in 0.25 second. In the oxygen atmos- 
phere, however, the toweling burst into complete flame within one half second 
from the heat of the fire and thus did not make contact with the fire itself; 
furthermore, it burned completely and partially melted the copper positioning 
wires. Under these conditions no smothering action of the toweling was possible. 
The candle continued to burn during all exposures to weightless parabolas, 
either in air at sea level pressure atmosphere or in a 5 psia 02 atmosphere. 


1. An artificial atmosphere of 100 per cent oxygen at an absolute pressure 
of 5 pounds per square inch presents a significant increase in fire hazard as 
compared with at an atmosphere of air at sea level pressure. This significant 
increase can be observed in the lowered ignition point and in the increased 
rate and temperature of burning. 

2. It is infinitely more difficult to smother fire in such an atmosphere 
than one in a sea level pressure atmosphere. 

3. A burning candle will not extinguish itself under conditions of 
weightles snes s . 

Flight Physiology Notes 

U. S. Naval Air Station, North Island, San Diego, California. 

A fundamental requirement of flight is keeping the take-offs and landings in a 
one-to-one ratio, keeping the aircraft in a reasonably intact and functional 
unit during and after these evolutions. This rather factitious statement also 
implies that when accomplished the occupant variously called "fly boy", "airdale", 
"bird man", "jet jockey", etc. , will also be returned in a reasonably intact 
functional unit. 

Man acts as a system component in the man-machine relationship we 
call aviation. In aviation the Naval Aviator reacts to various inputs from the 
machine, as for example, artificial horizon, air speed indicator, warning 
lights, tail pipe temperature, engine R. P. M. , manifold pressure, etc., as 
well as to intermittent voice inputs from the radio. He reacts to inputs from 
his cockpit and ambient environment such as vibration, engine sounds, clouds, 
rain, fog, lights, attitude, acceleration, and in addition he receives feedback 
to his muscles from the stick, rudder, and many other subtle input stimuli. 

U. S. Navy Medical News Letter, Vol. 44, No. 4 31 

From these inputs he makes decisions to perform certain control movements. 
These movements affect the machine which in turn furnishes new and different 
inputs to the pilot. This is called a closed loop system because it requires 
continuous interaction between the man and machine. In essence man becomes 
a biologic sensor, data processor, decision maker and controller component, 
inserted between the displays and the controls of the aircraft. Man and the 
machine have different capabilities and limitations, and each may be more or 
less affected by the environmental area in which they operate. By and large, 
the aircraft is specifically engineered and designed to operate within certain 
known physical environmental parameters, whereas man has a fixed design 
and will only operate effectively within the physical environmental parameter 
imposed by this design. There does not seem to be a newly engineered and 
redesigned human in the offering within the foreseeable future; it is therefore 
vital that the parameters of the physical environment for the aviator be main- 
tained within his design limits. We would like to provide protection against 
the wide range of physical environment in normal flight and the tremendously 
expanded parameters that could exist in any set of circumstances that may. be 
encountered from the time of his aircraft entry to his exit, which of course 
may be prior to the completion of the flight. All of this involves the commonly 
known devices such as cabin pressure and air conditioning, oxygen masks, 
hard hat, anti-G suits, poopy suits, restraint systems; pressure suits, sun 
visors, gloves, flash blindness protection, wind blast protection, survival 
kits, ejection seats, parachutes, etc. There is not complete agreement that 
the presently available equipment nor perhaps the methods or concepts used 
to protect man in the system is perfect. Particularly in relation to comfort, 
there is however, general agreement that it is effective and the best available 
in relation to the state of the art as it exists today. Constant and continuing 
efforts are being made to increase the effectiveness andto improve the "accept- 
ability quotient" of both the methods and the equipment that is so vital to the 
satisfactory mating of man and machine. Unfortunately the overall problem 
is further complicated by the fact that much of the time the Naval Aviator is 
not mated to his aircraft but is functioning in his normal environment, where 
he could and many times does impose severe stress on his biologic system. 
This becomes particularly important when one relates this to his role as an 
integral functioning part of the man-machine relationship of aviation. 

Because the non-flight status of the Naval Aviator so vitally affects 
his in-flight performance, it behooves us to examine and to discuss what might 
be called "pilot preventive maintenance". 

" We Are What We Eat " 

This old adage now has a new handle called "diet and nutrition" and it is of 
particular importance to flight personnel. In his role as a bio-sensor, 
computer, and data processor the pilot requires better than ordinary 
management of fuel replenishment in order to cope with the demands 

32 U. S. Navy Medical News Letter, Vol. 44, No. 4 

of flying. In addition the fuel intake should contain the proper proportions of 
fat, protein, carbohydrates, mineral and vitamins. 

In considering preflight human fueling one must include all foods in- 
gested for the 24 hour period prior to the flight, and not merely that food 
which is taken just prior to a flight. This is necessary because certain foods 
and drink, that are not compatible with optimum physical and mental efficiency, 
have effects lasting many hours. Ideally the preflight meal should be eaten 
under conditions which are relaxed and unhurried. Such a meal should be 
based on a daily calorie intake of from 3000 to 3600 calories depending on age, 
physical characteristics and length of time before the next meal. 

Flying involves only moderate exercise; therefore, one should eat to 
fly the aircraft, not to carry it. Large meals tend to inhibit or slow down 
digestion, overload the excretory organs and circulatory system and dull mental 
faculties. Meals should be moderate in size, fairly bland, palatable, easily 
digested and satisfying. The following is taken from the Air Defense Command 
Surgeon's Bulletin: 

"Total daily food intake should usually include items from all of the 
following food groups: 

Leafy, green and yellow vegetables - One or more servings daily, 

some raw, some cooked 
Citrus Fruits, tomatoes or salad - One or more servings daily 

Other fruits, other vegetables - Two or more servings daily 

and potatoes 
Milk and milk products - At least a pint of milk (for 

Adults) or equivalent in evap- 
orated or dried milk, cheese, 
ice cream or in cooking 
Meat, poultry, and fish - One or more servings daily 

Peas and nuts - Two or more servings weekly 

Eggs - Four or more per week; one 

or two daily preferred 
Bread, flour, cereal (whole - Two or more servings per 

grain, enriched or restored - day as needed 

Butter or fortified margarine - One or two ounces per day 

Other foods as needed for 
energy requirements 

The following are foods to be avoided : 

a. Greasy foods and any others containing excessive amounts of fats 

b. Highly concentrated carbohydrate foods (potatoes, bread, cake, 
candy, etc.) 

c. Highly seasonedfoods and condiments (including catsup, chili sauce, 
garlic, mustard, meat sauces, etc. ) 

d. Gas forming foods. Commonly considered to be "gas -forming are: 
Raw apples, melons, dried beans, peas and lentils, broccoli, 

U. S. Navy Medical News Letter, Vol. 44, No. 4 33 

cauliflower, cucumbers, parsnips, rutabagos, radishes, turnips, 
onions, green peppers, garlic, cabbage, brussei sprouts, and 
sauerkraut. These high roughage foods should be avoided whenever 
possible during a period of about 24 to 48 hours prior to flight. 
This follows from the fact that food usually requires about this long 
to pass through the intestinal tract. 

e. Foods high in roughage. Foods high in roughage which should be 
avoided in preflight meals are; bran products, celery and berries. 

f. Carbonated beverages shouldbe avoided for one or two hours before 

Skipping meals prior to flights can be as dangerous as overeating; this 
is especially true if the meal skipped is the .morning meal. No one in their 
right mind would consider taking-off with practically no fuel on board, yet if 
you take a morning hop without an adequate breakfast, this is exactly what you 
are doing. The time from the evening meal to the morning meal is usually the 
longest period of time, (8-12 hours), in which no food has been consumed and 
if this important meal is missed, hypoglycemia results. Blood sugar is the 
basic source of energy to the body and when it is low you are more easily 
fatigued, have slower reaction time, are more irritable, weak and mentally 

" Eat to Live, but Don't Live to Eat I " 
Alcohol and the Naval Aviator 

Spiritus Frumenti, alias joy juice, booze, hootch, sneaky pete, alky, 
moonshine, torpedo juice, firewater, etc. , is a much mis understood beverage. 
Alcohol can be and is burned by the body and has some food value. Usually it 
is not consumed for its food value, but rather for the effect it produces on the 
higher brain centers. Most people think of it as a stimulant and "tuner-upper", 
whereas in reality it is a depressant and a relaxer of self-control and discrim- 
ination. In suitable doses it is found by many people to increase the enjoyment 
of congenial company and tolerance to the boors. As the dosage is increased 
everyone, including the boors, appear congenial and the imbiber becomes the 
boor. Alcohol differs from other sources of energy in that it can be absorbed 
directly from the stomach and, therefore, its effects are more rapidly experi- 
enced. The food value of alcohol is, however, limited because there is no 
storage mechanism and because of the inconvenient side effects such as diuresis, 
mental confusion and loss of muscular coordination. To make matters worse 
alcohol, like narcotics and such poisons as cyanide, interfere with the ability 
of the body's cells to use the oxygen available to them. 

Did You Know ? 

1. 35.4 percent of the total general aviation FATAL accidents studied were 
positive for blood and/or tissue alcohol. 

34 U. S. Navy Medical News Letter, Vol. 44, No. 4 

2. Almost one-half of the alcohol -positive group crashed within 18 minutes or 
less after takeoff. 

3. The accepted legal limit of blood alcohol is 150 mg/ml andthat flying skills 
are measurably decreased by ONE FOURTH THE AMOUNT necessary to pro- 
duce a measurable decrease in automobile driving skills. 

4. In the alcohol- positive group that crashed the average alcohol level was, 
on autopsy, found to be 145 mg/ml. 

Flying when obviously drunk has never constituted a significant problem, 
but the problem is significant in flying when the blood alcohol content is still 
highenoughto impair maximum effectiveness and /or when the pilot is suffering 
from hangover. It takes the average individual about 3-4 hours to burn one 
ounce of alcohol; therefore, if not more than three one-ounce alcoholic drinks 
are consumed it appears safe to fly 12 hours after the last drink. Many inves- 
tigators recommend that the time period between drinking and flying be 24 
hours. (See OPNAV INST. 3740. 7) 

Intelligent understanding and MODERATION form the keynote of any 
discussion of food and drink. SEE YOU AT HAPPY HOUR! I '. '. 1 ? 

Examination Other Than the Annual Physical 

Few people voluntarily seek medical examinations except when untoward 
symptoms develop to the stage that they become annoying, or normal functions 
are upset. The annual physical is mandatory and is designed to detect early 
or insidious evidence of disease processes. But in aviation this is not sufficient 
and it is suggested that the Squadron Flight Surgeon perform random unannounced 
physical examinations on his squadron pilots with the goal of detecting and 
preventing any condition that interferes with or causes a decrement of the 
pilot's effectiveness in his role as a Naval Aviator. In order for this to be 
effective there must be good rapport between the Flight Surgeon and the members 
of his- squadron and the squadron members should be properly oriented toward 
the value of this examination. By orientation toward the examination we mean 
that the procedure must be fully explained, what the examination will include, 
what it can and cannot reveal. It should be stressed that detection of many 
disorders depends in a large part on the frankness and honesty of the examinee. 
Important to this program is whole hearted support by the Commanding Officer, 
and his willingness to accept, back up and follow the advice of the Flight 
Surgeon. If the Commanding Officer is told by his maintenance officer that a 
certain aircraft is down he admittedly will "get on" the maintenance office to 
get it up, but he won't fly the aircraft until it is in an up status. This same 
attitude should prevail where the flight surgeon reports that a pilot is down. 

Air Division Aviation Medicine Unit 

By F/L JA Firth, CD Aeromedical Reports 1964. 

Although the RCAF has had an Air Division in Europe since 1953, it is only 

U. S. Navy Medical News Letter, Vol. 44, No. 4 35 

since last year that it has had its own aviation medical facility. Up to that 
time we had been able to use the facilities at the USAF base at Wiesbaden, and 
we have been most grateful for being able to conduct our training there. 
Throughout the past few years, however, it was becoming increasingly evident 
that this arrangement, although meeting indoctrination and decompression 
requirements, was not giving direct support to the operational task of the 
division and would give even less as it became more specialized in the strike- 
reconnaissance role. In addition, the distance from the air division units to 
Wiesbaden meant that each person going there on a course was away fromhis 
unit for at least three days. With these and other considerations in mind a 
unit was planned at Zweibrucken and, after many setbacks, came into being in 
1963. The planning and equipping of the unit were very largely the work of 
S/L WJC Stevenson, who was flight surgeon in the air division from 1959 to 
1963, and F/LJ Soutendam, who was stationed at Wiesbaden during the same 
period. It was unfortunate for these officers that their tour in Europe expired 
just at the time the new unit was completed, but all was in readiness for the 
new staff to take over their duties and run the first refresher indoctrination 
course on 29 Aug 63. 

The Unit consists of one arm of an "H" type barrack block and contains 
a briefing room, Flight Surgeon's office and examining room, Aeromed Training 
Officer's office, orderly room, chamber room, investigation and recovery 
room, workshop, waiting room, and toilet facilities. The staff consists of 
the Air Division Flight Surgeon, the Aeromedical Training Officer, a Sgt and 
two Cpl BioTechs, and a typist. 

Two types of formal High Altitude Indoctrination courses are presently 
offered: an eight hour course for experienced aircrew, and a 14 hour course 
for inexperienced aircrew, and in the first three months of operation fifty 
personnel had received these courses, which are oriented towards the T33. 
Special courses for CF104 aircrew are planned to start early in 1964 and are 
directed specifically at the role of this aircraft. The primary subjects will 
be: human performance limitations in respect to available time, vision at low 
level, disorientation, ejection procedures, physical and mental hygiene, 
personal equipment, and the summation of physiologic stresses with their 
implications concerning pilot error. 

One of the major functions of the unit is to provide a central point for 
the aeromedical activity of the Air Division and provision has been made to 
attend to all problems relating to personal flying equipment, the medical in- 
vestigation of individual aircrew problems, and the human engineering aspects 
of flight and ground safety. Very close liaison is maintained with all flight 
safety personnel, simulator personnel, and those concerned with accident 
investigation. In order to keep abreast of current problems and techniques 
the Flight Surgeon also performs the duties of the 3 Wing Flight Surgeon and 
is responsible for the medical care of the aircrew operating from 3 Wing. 

Some of the many minor support functions might be briefly mentioned. 
It is anticipated that the unit personnel will eventually form the nucleus of an 

36 U. S. Navy Medical News Letter, Vol. 44, No. 4 

Air Division search, rescue, and crash investigation unit and the necessary 
equipment towards this end is being assembled. An aeromedical reference 
library for the use of Air Division has been formed. The personnel are active 
in all aspects of ground safety, and economical methods of ensuring an effec- 
tive hearingconservation programme are under study. The latter programme 
will probably be monitored from the unit. Liquid oxygen is a source of contin- 
uous concern and its quality control programme requires constant attention 
and coordination. 

In short, the overall aim of the unit is to achieve maximum utilization 
of the aeromedical capability within the Air Division andto apply that capability 
to the support of the operational task of the Division. 

7$ 3}! Tfi 2QC 3jC 3$! 

New Section 

A Look at Our U, S, Naval Hospitals Yokosuka ' 1 ' 

By CAPT R. E. Faucett MC USN Chief of Medical Service 

Intern Training. On 16 October 1951, a preliminary letter was sent from Gen- 
eral Headquarters, Supreme Commander of Allied Powers to the Surgeons of 
the three branches of the Armed Forces in Japan in which possibilities for 
establishment of an observership for select Japanese medical students in the 
ArmedForces Hospitals was suggested. After considerable discussion at local 
and Washington levels, the Bureau of Medicine and Surgery of the U. S. Navy 
agreed to cooperate in establishing such a training program and directed the 
Commanding Officer, U. S. Naval Hospital, Yokosuka, to implement such a 

Subsequently, inconjunction with the Public Health and Welfare, Medical 
Section, SCAP, and the Japanese Ministry of Health and Welfare, a program 
was prepared. Agreements were concluded regarding screening, examining 
{including physical) and final selection of candidates for intern training who 
were recommended by the Deans of medical schools through the Ministry of 
Health. Seven candidates were selected to start intern training on 1 May 1952 
at the U. S. Naval Hospital, Yokosuka. This was the largest group at any of 
the Armed Forces hospitals in Japan; the U. S. Army and Air Force each had 
4 interns at 11 participating hospitals. Six members of this class eventually 
completed the whole year of training. This was on a purely voluntary basis 
without pay with official designator "observer intern". 

In 1953, there were no candidates. In 1954, Dr. Kenzo Yada, a recent 
graduate of Keio University School of Medicine, came to the U. S. Naval Hos- 
pital, Yokosuka, and requested permission to spend one year at his own expense 
in observership capacity. Although there was no formal program, Dr. Yada 
received excellent instruction from all staff members. The Japanese Ministry 
* Continued from U. S. Navy Medical News Letter, Vol. 44, No. 3. 

U.S. Navy Medical News Letter, Vol. 44, No. 4 37 

of Health later granted approval for his training and he thus became the 7th 
graduate from the training program. 

On 22 July 1954, the Bureau of Medicine and Surgery officially approved 
the intern training program in the U. S. Naval Hospital, Yokosuka, with 4 
billets. This was increased to 6 on 22 October 1956, from 5 to 8 on 22 November 
1957, from 8 to 13 on 5 November 1958 and from 13 to 14 on 13 October 1959. 

With the reassignment of intern billets in the Tri-Service hospitals, 
incident to the disestablishment of the 6022nd U.S. Air Force Hospital, Johnson 
Air Force Base, in November 1962, these 6 billets were temporarily assigned 
to the U. S. Air Force Hospital, Tachikawa. However, on 1 March 1963, U. S. 
Naval Hospital, Yokosuka, increased their billets from 14 to 16. Thus, since 
its inception in May 1952 to the present date, a total of 84 Japanese medical 
students have completed internship training at this hospital. 

Prior to 1959, each candidate submitted his application through the 
Japanese Ministry of Health to the respective Armed Forces hospital of his 
choice for training. Each hospital intern committee, therefore, examined the 
candidates and selected the successful ones. In I960, the Tri-Service 

Intern Committee, representing each of the 3 participating hospitals, conducted 
the professional and physical examination of all candidates on the same date 
with final selection made upon a matching system similar to that used in the 
United States. The total number of candidates appearing for the examination 
in I960 was 67, 1961 was 76, 1962 was 106, and 1963 was 107, 

The Tri-Service Internship is officially approved by the Japanese 
Ministry of Health. The interns have hada spectacular success in the National 
Board Examinations as well as the Educational Council for Foreign Medical 
Graduates Examinations. Many have been successful candidates for graduate 
training in the United States and Germany. Several have won Fulbright Scholar- 
ships. The training program is quite similar in extent and scope tothat offered 
in hospitals approved for graduate training in the United States. Quarters are 
provided in each hospital. Basic pay as of 1 July 1963 was 22, 400 yen ($62. 22) 
a month. Laundry is provided. Meals are available at reasonable cost within 
each hospital. The interns are considered as staff members of each hospital 
and enjoy certain base privileges as a result of this status. 

A total of 100 interns have now completed this training program. In 
response toan alumni letter sent last March 1964 (only 80 answered), we learned 
that many former interns went to the United States of American for further 
graduate training. At present, we know of 32 interns who are in the United 
States of America under graduate training programs. 

Of our former interns, 14 have now returned to Japan and occupy promi- 
nent positions on the faculty of various medical schools andteaching institutions. 

The great majority of graduates of the U. S. Naval Hospital Yokosuka, 
intern training program continue in postgraduate work in Japan especially in 
research projects, leading in four years to advanced degrees in medicine. This 
year, at the Fourth Far East Session of the American College of Physicians 
held at U. S. Naval Hospital, Yokosuka, Japan, five ex-interns from 
this hospital were either principal speakers or coauthors of papers accepted 
for presentation. 


U. S. Navy Medical News Letter, Vol. 44, No. 4 

Official U. S. Navy Photograph, USNH Yokosuka, Japan 

New Intern Class of 1964-65 
(Left to Right) 
Top Row : Dr. Aoki, Dr. Konishi, Dr. Ogawa, Dr. Arai, Dr. Yamamoto, 

Dr. Watanabe 
Middle Row: Dr. Kobayashi, Dr. Tateishi, Dr. Shibata, Dr. Lee, Dr. Kanehira, 

Dr. Tashiro, Dr. Inoue 
Bottom Row: Dr. Fuji, Capt Suitor (Executive Officer), Capt Davis (Command- 
ing Officer), CaptFaucett (Chief of Medical Service), Dr. Yama- 
guchi, Dr. Matsui 
In summary, since 1960-61, 58 interns have completed training, 56 
took the examination for certification by the Educational Council for Foreign 
Medical Graduates; 40 have permanent certification; 12 have temporary; only 
4 failed. 

This program has always received the cooperative support from the 
U. S. Embassy, Tokyo, Japan. The Honorable John K. Emmerson, Deputy 
Chief of Mission, U. S. Embassy, Tokyo, Japan, delivered the commence- 
ment address to the 1962-63 and 1963-64 classes speaking in English and in 
Japanese. U. S. Naval Forces Japan has provided financial support for the 
intern reception held each year following graduation ceremonies in the Com- 
missioned Officers' Club. Approximately 150 people regularly attend this 
function. Many representatives of the Japanese Self Defense Forces as well 
as distinguished educators join parents and friends in this gala and festive 

At the moment there is countrywide interest in and enthusiasm for the 

U. S. Navy Medical News Letter, Vol. 44, No. 4 39 

intern training program in Japan. One-year of intern training is a prerequisite 
for licensure. However, very few hospitals in Japan have an organized intern 
training program similar to that seen in the Tri-Service Hospitals or in the 
United States of America. To illustrate the fine quality of training available 
to outstanding Japanese medical students, and, in an attempt to create new 
interest and support in the intern training program in general, the Tri-Service 
Intern Training Program has been featured on three television shows (two 
describing the program at U. S. Naval Hospital, Yokosuka, and one at U. S. Air 
Force Hospital, Tachikawa). This has given the U. S. Naval Hospital, Yokosuka, 
great commendatory publicity, particularly for our participation in the Presi- 
dent's People-to-People Program. 

I hope that this brief resume will give some idea of the interest, support 
and enthusiasm we at Yokosuka have for this wonderful program. We con- 
sider it a Per son -to -Per son Program because we become so intimately concerned 
with the welfare of our medical confreres that we naturally become vitally 
aware of the problems, cultural aspects, mores, etc., of the Japanese. Through 
such direct and interested contact we communicate with and learn to live with 
one another. In effect, we live in God's admonition to serve as our Brother's 

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Restrictions Concerning Special Active Duty for Training 
Taken from BuPers Itr Pers Da/ek Serial: 894 dtd 29 Jul 64 

1. In past years it has been possible to authorize tours of ACDUTRA in excess 
of 14 days, or second tours of ACDUTRA, in certain instances where direct 
support was thus provided for the accomplishment of the Naval Reserve mission. 

2. While the need for such support is recognized, the fact that the Naval Reserve 
is operating at or close to its authorized drill-pay ceiling requires continuation of 
the restrictions imposed late in fiscal year 1964. 

3. Accordingly, the following criteria are established until further notice: 

a. Special ACDUTRA authorizedby Bureau of Naval Personnel directive, 
or for a planned and budgeted program such as school or special tours (e.g. 
the Accelerated Program, the Medical Clinical Clerkship Program, ROC 
instructors, or Reserve Recruit School Staffs) continues in effect. 

b. Authority will not be granted to issue orders for more than 14 days 
ACDUTRA with pay or for additional periods of ACDUTRA with pay in cases 
where authority is not extended as above. 

4. Special ACDUTRA in support of Research Seminars, Mobilization Team 
and Telecommunications Exercises, planning conferences, advance or clean-up 
parties for Reserve Mobile Construction Battalion ACDUTRA, additional tours 


U. S. Navy Medical News Letter, Vol. 44, No. 4 

of ACDUTRA in Classification or Instructors schools for Reserve Construction 
Battalion personnel, Reserve program conferences, and. other special requests 
from individuals or activities are not authorized. 

5. These restrictions will be reviewed later in the fiscal year, and relaxed 
if circumstances permit. 

New Film Ready for Showing 

A 17 -minute motion picture, "M-Day", which describes anew concept for Naval 
Reserve mobilization procedures, is available for showings. It tells how the 
Navy keeps track of its inactive personnel through centralized records, and 
how they will be mobilized in the event of a national emergency. The Naval 
Reserve Manpower Center prepares and sends the new Navy mobilization order 
(Active Duty Order, NavPers 4035} to an order-issuing activity. The film uses 
as its example a Naval Reserve Training Center designated as a post -M-Day 
mobilization station. At this NRTC, before mobilization, active duty personnel 
are shown administering Category "A" pre-ordered Reservists' orders. The 
Naval Reserve Mobilization Team (Category n A" Reservists themselves), 
attachedto this training center, maintain the Category "B" pre-selected Reser- 
vists' orders. The procedures for recalling and processing these Reservists 
upon mobilization are shown. 

The film traces the administrative procedures involved in the recall 
of inactive personnel, from the preparation and delivery of an individual's 
order, to the point where he reports to his duty station or ship. Reserve 
activities may obtain the training film (MN-10020) through normal distribution 
channels. The Naval Reservist, NavPers 15653, July 1964. 

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